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SAN;10AQCV, COUNTY <br /> f,N�iRONMEi of ,i,�11AI i i <br /> 600 Fast Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsigov.orweh <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fa lity Name: Inspec on Date: <br /> do <br /> ey <br /> Fac lity Address: - Service Request#: <br /> ` � ���,a` 1 I v�• ���'l� U� �� �?L) r ' (1 ( )fir- (� <br /> Onsite Service Technician's Name: ICC Service_Technician/installer Certification#: yanufacturreJr/Trraaiinin • <br /> PI/I <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: — <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor - <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> r-1 � ' � ❑ si <br /> El fail safe Serial # p <br /> ❑ NA minutes <br /> ".: �,. sensor <br /> positive shutdown Model: ��, I Q � '(, ;? Secondary piping testing at: <br /> fail safe Serial #: �1: �� ❑ _--psi <br /> NA minutes <br /> sensor Secondary containment repairs for: <br /> ElpositiveUDC(s) Piping <br /> positive shutdown Model: g <br /> ❑ ❑ fail safe Serial #: <br /> El NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ( �� 14 ►� �)L 12242 -1 Ar <br /> THIS FACILI IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH Inip t —�� Rec Title: <br /> EHD 23-04 <br /> Rev 060^/07 <br />